Learning impact of education during
Pulmonary Rehabilitation program.
An observational short-term cohort study
E. Crisafulli
1, S. Loschi
1, C. Beneventi
1, A. De Biase
1,
B. Tazzioli
1, A. Papetti
1, C. Lorenzi
1, E.M. Clini
1,2Introduction
Pulmonary Rehabilitation (PR), a non-pharma-cological comprehensive intervention for disabled chronic respiratory patients, proves effective in terms of exercise tolerance and perceived symptoms (e.g. dyspnoea and/or fatigue) in Chronic Obstruc-tive Pulmonary Disease (COPD) individuals [1]. Among the several components integrating a formal rehabilitation setting, education and self-management may substantially contribute to the individual’s early recognition of symptoms and worsening of the disease [2, 3], through recalling information on the pathophysiological alterations and reinforcing skills.
Actual recommendations always suggest in-cluding education during PR course, nonetheless, the relative and specific effectiveness of this com-ponent throughout is still not sufficiently docu-mented to health care providers [4].
The present preliminary study, therefore, has been undertaken to assess the learning impact of structured educational sessions (ES) applied
dur-ing a standard PR program delivered to disabled COPD patients.
Methods Patients
Patients suffering from COPD referred to our clinic for rehabilitation purposes in between Janu-ary and December 2008 were studied. Diagnosis and classification were according to the Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) guidelines [5].
Only clinically stable patients entered the study. Those suffering from recent acute exacerba-tion of their disease (in the preceding 4 weeks) were excluded. Moreover, patients with respirato-ry conditions other than COPD (either obstructive or restrictive), associated malignancies, or any un-stable clinical condition (e.g. severe heart failure, neuro-motorial conditions) which might have in-terfered with adherence, or patients with cognitive impairment that might have interfered with
under-Keywords: Education, COPD, Rehabilitation, Self-management.
1Villa Pineta Hospital, Pulmonary Rehabilitation Unit, Pavullo n/F (MO),
2University of Modena, DAI Oncology, Haematology and Pneumology, Modena, Italy.
Correspondence: Prof. Enrico M. Clini, University of Modena and Ospedale Villa Pineta, Dept. of Oncology, Haematology and Pneumology, Ospedale Villa Pineta, Via Gaiato 127, 41026 Pavullo (MO), Italy; e-mail: enrico.clini@unimore.it
ABSTRACT: Learning impact of education during
Pulmonary Rehabilitation program. An observational short-term cohort study. E. Crisafulli, S. Loschi, C. Beneventi, A. De Biase, B. Tazzioli, A. Papetti, C. Lorenzi, E.M. Clini.
Background. Among the several components
consti-tuting a pulmonary rehabilitation (PR) course, education may contribute to an individual’s recognition of symptoms and worsening of the disease. However, the specific bene-fits of education is far greater than can be clearly docu-mented to the health care providers. The aim of our pre-liminary study was to assess the learning impact of educa-tional sessions (ES) in Chronic Obstructive Pulmonary Disease (COPD) patients referred to standard PR.
Methods. Six ES on 3 areas (Symptoms-Therapies,
Aids, Mood) were applied during PR at our clinic. The learning effect was prospectively evaluated by a specific questionnaire (ESQ) in 285 COPD patients (age 69±8 years, FEV153±14 % pred), then grouped into those who
have completed ES (Completers group, n=226) or who did not (mean 2±1 ES) (Control group, n=59). Total and par-tial ESQ scores, and PR outcomes (6-minute walking test-6MWD, effort-dyspnoea at Medical Research Council scale-MRC, and health-related quality of life scale-SGRQ) were assessed in a pre (T0) to post (Tend) design.
Results. Similar improvement in PR outcomes was
recorded in both groups at Tend, whereas ESQ total and partial scores significantly increased in ‘Completers’ only (p<0.001). ESQ-Aids score improved to a greater extent in
Completers than in Control (+0.60±1.03 vs +0.27±1.27
point respectively, p=0.036). A higher proportion of
Com-pleters improved above the median change of both ESQ to-tal and aids scores (p<0.05).
Conclusion. Attending educational sessions produces
a specific short-term learning effect during rehabilitation of COPD patients.
Fig. 1. - Study flow diagram. PR: Pulmonary Rehabilitation; ES: Educational Sessions.
selected COPD patients performed a standard PR program with outcome measures taken at the be-ginning and immediately prior to discharge; details on this program have been reported previously from our group [6]; each daily session lasted three hour and included endurance and resistance train-ing of the peripheral muscles, as recommended [1]. Educational course (see below), psychological and/or nutritional support (if appropriate) complet-ed the program.
The duration of PR was over a minimum of 15 consecutive sessions.
Educational course
This was provided by 6 different ES lasting 1 hour each, which integrated the rehabilitation pro-gram. Patients were grouped to attend each lesson in the morning at the same time and following the training activities, but they were left free to choos-ing if they wanted to participate in each lesson.
Lessons were held for pertinence by different “health educators” (physician, respiratory thera-pist, nurse and psychologist) on the following top-ics: anatomy and physiology of pulmonary system, standing and learning, were not included. All the
selected patients gave their informed consent to participate in the study.
Figure 1 shows the flow diagram of the study cohort.
Study design
The institutional review board at our hospital approved this observational study; all procedures were conducted according to the Declaration of Helsinki.
The study design was a prospective short-term
pre-to-post comparison of measurements in all
in-dividuals. Comparison was made in the whole sample and between the following two groups: pa-tients who have completed all the educational ses-sions (ES) (Completers group, n=226), or those who did not (number of ES=2±1) (Control group, n=59) due to clinical or personal reasons.
PR program
The patient’s selection to PR was made ac-cording to the ATS/ERS joint statement [1]. All the
early recognition of symptoms and signs of exac-erbation (physician), role of muscle training and chest physiotherapy in pulmonary diseases (respi-ratory therapist), domiciliary use and management of respiratory aids, oxygen or drug inhalers (nurse and respiratory therapist), management of mood disturbances (psychologist).
Access to each ES was registered and atten-dants signed their presence.
Any other specific information and/or educa-tional material (i.e. brochure) on specific non in-cluded topics were also encouraged and proposed to each patient according to his/her individual needs; however, these topics were covered over and above the standard delivery of ES.
Measures
GENERAL DATA
Anthropometric and demographic characteris-tics of all the selected patients were collected at study entry. Lung function in terms of dynamic volumes (forced expiratory capacity in the 1st sec-ond-FEV1, and FEV1to forced vital capacity-FVC ratio) was recorded by means of a spirometer (Masterscope; Jaeger; Hoechberg, Germany); pa-rameters were expressed both as absolute or per-centage of predicted values according to the equa-tion of Quanjer [7].
OUTCOME MEASURES
These measurements were taken within 24-48 hours from the beginning of PR (T0) and immedi-ately prior to discharge (Tend) after the program has been completed.
LEARNINGQUESTIONNAIRE
A specific questionnaire (ESQ) completed by all patients in the study (without the assistance of any operator) represented the clinical tool we used to assess the level of patient’s knowledge and the learning impact of the ES course. This multiple-choice questionnaire (see Appendix) was com-posed of ten questions (one correct answer for each question) grouped in three different areas:
Symptoms-therapy, Aids, Mood. Questions were
previously elaborated and selected by our multi-disciplinary group and judged on “what is relevant
for the patient to know” in each topic. A formal
group brainstorming and evaluation of website ac-cessible materials for COPD patients [8] preceded the questionnaire composition.
For each correct answer 1 point was assigned, the total score therefore ranged from 0 (minimum) to 10 (maximum).
SPECIFICPR MEASURES
Exercise tolerance, as measured by 6-minute walked distance (6MWD) [9], perceived effort-dyspnoea, as recalled by means of a five-point (0 as best, 4 as worst) modified Medical Research Coun-cil (MRC) scale [10], and specific health-related quality of life questionnaire (St. George’s Respira-tory Questionnaire-SGRQ) validated in Italian lan-guage [11], were recorded as general PR outcomes.
Statistical analysis
Statistical analysis was carried out using SPSS software (SPSS 8.0 for Windows; SPSS, Chicago, IL). All values are expressed as mean (with SD) or frequency (nr or %) and presented in the whole co-hort or in the two groups. Statistical comparison between groups and times for different size para-meters was made using test t of Student and by a General Linear Model. The Wilcoxon and Kruskal-Wallis tests were applied for comparison of non-parametric variables. A chi-square test was added for comparison between number (and %) of pa-tients in each group who improved above the me-dian change of the questionnaire scores (total and partial).
In any case a result with a statistical probabili-ty (p) <.05 was considered to be of significant dif-ference.
Results
296 COPD patients were selected for this study and of them 285 (66% male) completed the rehabilitation course and had their results analysed (see figure 1). Withdrawal rate from PR was there-fore about 4%.
Most of these patients (79%, n=226) complet-ed ES course and were thus groupcomplet-ed into
Com-pleters, whereas 59 remained as Control.
68% of controls did not complete ES due to voluntary withdrawal (they did not attend the scheduled lessons), while the remaining 32% had clinical problems (intercurrent symptoms such as worsening dyspnea, malaise, back or joint pain) which temporarily precluded their chance to reach the educational room.
The baseline descriptive characteristics of pa-tients are shown in table 1. 67% of them were in stage III and IV according to GOLD classification, whereas 30% were on long-term oxygen (LTOT) at home. No differences were recorded between groups.
Table 2 shows total and partial ESQ scores, as recorded at study entry, which were similar in the two groups. Analysis of pre-to-post group compar-ison of both specific PR outcomes and ESQ scores is shown in table 3. Exercise tolerance and per-ceived effort-dyspnoea significantly (p=0.001) and similarly improved in both groups, whereas ESQ total and partial scores significantly changed (p=0.001) in Completers. The analysis of differ-ence of both ESQ absolute value (table 4) and the proportion of patients who improved above the median change of the questionnaire scores (table 5) as obtained after PR further confirmed a signif-icant change in favour of Completers.
Discussion
It is likely that educational component of a structured comprehensive rehabilitation program may attract individuals to a more active participa-tion and collaboraparticipa-tion (compliance) in the rehabil-itative track. Indeed, compliance is almost known
to represent a “key point” of success in PR [12]. In the present study, about 80% of patients attended and completed the ES. This is new and interesting data which has emerged from real life. A recent study in PR found approximately a 90% atten-dance rate among outpatients COPD [13], but gave no information on attendance rate at any single PR component including education course.
Over recent years, the role of education is con-sidered to be of increasing interest for COPD pa-tients’ management. A current method of teaching by means of frontal lessons is a useful means of in-structing patients regarding their disease and its consequences, and to challenge them through change in lifestyle to accomplish the best possible control of their clinical condition once at home [14, 5].
Although literature still shows no firm and consistent benefits from formal education [16-18] two recent studies centred on patient’s
“self-man-agement” with the aim of recognising exacerbation
as early as possible, resulted in substantial reduc-tion of hospitalisareduc-tion rate over 1-year [3] and up to 2-year [4] of follow-up.
Our study documented that educational ses-sions produce a specific short-term learning effect during a standard rehabilitation program in COPD patients, in particular regarding the management of respiratory aids (e.g. oxygen or devices for in-haled therapy) in daily use. In a narrow analogy with previous studies [19] and international guide-lines [1, 2], effectiveness of PR program in terms of general function is here provided by results of both exercise tolerance, breathlessness and
healtd-Table 1. - Anthropometric and clinical characteristics in the study cohort. Data presented as mean (SD) of percentage value
Study Cohort Completers Group Control Group
p (n=285) (n=226) (n=59) M:F nr 188 / 97 151 / 75 37 / 22 0.502 Age years 69.9 ± 8.0 70.2 ± 8.2 68.2 ± 6.7 0.128 BMI kg·m-1 26.0 ± 4.8 25.7 ± 4 2 26.1 ± 4.0 0.451 FEV1 l. 1.05 ± 0.58 1.01 ± 0.49 1.08 ± 0.63 0.309 % pred. 53.4 ± 14.4 50.1 ± 12.9 54.5 ± 10.0 0.186 FEV1/FVC % 53.7 ± 12.8 54.1 ± 10.1 52.3 ± 11.5 0.865 GOLD staging 0.128 Mild nr (%) 4 (1.4) 3 (1.3) 1 (1.6) Moderate nr (%) 91 (31.8) 63 (27.8) 28 (47.4) Severe nr (%) 85 (29.9) 71 (31.4) 14 (23.7) Very severe nr (%) 105 (36.8) 89 (39.3) 16 (27.1)
M: male; F: female; BMI: Body Mass Index; FEV1: Forced expiratory volume in 1st sec; FEV1/ FVC: Tiffenau index or ratio
FEV1/FVC, Forced vital capacity; GOLD: Global Initiative for Chronic Obstructive Pulmonary Disease.
Table 2. - ESQ scores in the study cohort as assessed at admission. Data presented as mean (SD)
Study Cohort Completers Group Control Group
p (n=285) (n=226) (n=59) Questionnaire scores SYMPTOMS-THERAPY score 2.75 ± 1.06 2.74 ± 1.02 2.79 ± 1.22 0.734 AIDS score 2.60 ± 0.95 2.60 ± 0.92 2.62 ± 1.06 0.856 MOOD score 1.24 ± 0.70 1.24 ± 0.69 1.25 ± 0.73 0.950 TOTAL score 6.63 ± 1.85 6.59 ± 1.79 .67 ± 2.08 0.417
Table 3. - Time course of specific PR outcomes (Part A) and ESQ scores (Part B) as assessed throughout PR. Data presented as mean (SD)
PART A Completers Group Control Group
(n=226) (n=59) p* T0 T end p T0 T end p 6MWD meters 354.6 ± 101.7 422.7 ± 107.1 0.001 354.2 ± 88.0 429.3 ± 85.5 0.001 0.844 MRC score 3.25 ± 0.93 2.22 ± 0.90 0.001 3.46 ± 0.89 2.42 ± 0.86 0.001 0.178 SGRQ score 36.33 ± 14.65 25.52 ± 12.91 0.001 34.45 ± 15.18 24.38 ± 10.69 0.001 0.423
PART B Completers Group Control Group
(n=226) (n=59) p* T0 T end p T0 T end p Questionnaire scores SYMPTOMS-THERAPY score 2.74 ± 1.02 3.21 ± 0.91 0.001 2.79 ± 1.22 3.00 ± 1.14 0.171 0.825 AIDS score 2.60 ± 0.92 3.20 ± 0.84 0.001 2.62 ± 1.06 2.89 ± 1.09 0.107 0.956 MOOD score 1.24 ± 0.69 1.49 ± 0.63 0.001 1.25 ± 0.73 1.42 ± 0.67 0.086 0.709 TOTAL score 6.59 ± 1.79 7.91 ± 1.80 0.001 6.67 ± 2.08 7.20 ± 2.21 0.077 0.747
6MWD: 6-min walked distance test; MRC: Medical Research Council breathlessness score; SGRQ: St. George’s Respiratory Questionnaire total score. * Comparison between groups (Completers vs Control groups).
Table 4. - Analysis of difference in ESQ scores between groups as obtained at discharge (Tend). Data presented as mean (SD)
Study Cohort Completers Group Control Group
p (n=285) (n=226) (n=59) Questionnaire scores (∆) SYMPTOMS-THERAPY score + 0.41 ± 1.02 + 0.46 ± 0.99 + 0.20 ± 1.12 0.077 AIDS score + 0.53 ± 1.09 + 0.60 ± 1.03 + 0.27 ± 1.27 0.036 MOOD score + 0.22 ± 0.75 + 0.24 ± 0.75 + 0.16 ± 0.74 0.502 TOTAL score + 1.22 ± 1.85 + 1.31 ± 1.79 + 0.86 ± 2.03 0.094
∆: Difference of variables obtained between the end and begin of PR program.
related quality of life (table 3, part A), which did not parallel the observed gain associated with learning (table 3, part B).
Both total and partial ESQ mean scores signif-icantly improved at the end of the rehabilitation period only in patients who fully attended the edu-cational course, while they remained unchanged in those patients who did not. In addition, both analy-sis of difference of ESQ absolute value (table 4) and the proportion of patients who improved above the median change of the questionnaire scores (table 5) confirmed the adjunctive gain on learning in Completers only.
It is likely that direct message of our educa-tional lessons supported this result, thus enabling
patients who complied with all the lessons to achieve this extra gain irrespective on their severi-ty and/or functional complexiseveri-ty (i.e. presence or absence of respiratory failure).
Despite the lack of unequivocal scientific evi-dence on the real learning benefit from a single therapeutic modality in patients with COPD [20, 21], education component has the aim not only of encouraging the active participation and collabora-tion of the rehabilitacollabora-tion program but also (and es-pecially) to “teach” some technical and behaviour-al aspects of daily living.
The aim of this type of learning would be to fo-cus the patient’s attention on the chronic aspects of his/her disease, such as the early signs of
exacer-bation, to prevent unfavourable consequences [22] and to increase general adherence to therapies [8, 23], in other words to improve the “self-effica-cy” [3]. Indeed, it’s commonly recognised that COPD exacerbation may cause several clinical ad-verse events both at lung [24] or systemic level [25], thus increasing health-care costs [26] and mortality [27]. The correct delivery of drugs and the use of respiratory aids represent aspects of main importance in the long term. When compared to those patients who failed to fully attend the ES in our study, the proportion of COPD patients who completed the educational course reported a sig-nificantly higher change of ESQ-Aids score above the median observed absolute change (table 5), which is likely to enable them to improve these skills even after returning home.
Given that compliance is a key element in the management of chronic diseases and patient’s ad-herence to therapies [28] a formal program of edu-cation has not only the aim of “teaching” concepts and “training” techniques, but also to “educate” the patients; so that, he/she becomes more aware of any consequence derived from a irresponsible use or a no-use of requested devices and aids. This might further translate in a true economic advan-tage in the long-term; indeed, cost saving from change in lifestyle has been already demonstrated in COPD [29].
Notwithstanding, our study presents several limitations. First, the absence of a control group, we have only assessed the learning effect of a spe-cific intervention in a short period after rehabilita-tion nor we did assess the patients’ change in lifestyle after program discharge over a formal longer follow-up. Therefore, we can only specu-late any further advantage in the patient’s daily liv-ing once he/she returned home.
Second, one should note the very different amount of patients in the two study groups. The number of control patients was determined ex post since we did not expect precisely the rate of ad-herence to our ES course (which can vary consis-tently in different population and/or setting).
Future studies with a randomised trial design should address the short and (hopefully) long-last-ing effect derived from a structured educational pro-gram in COPD patients, and even assess the possi-ble cost-benefit advantage of such intervention.
In conclusion, our preliminary research has fairly shown that attending formal education is likely to produce a specific learning effect during standard rehabilitation delivered to COPD pa-tients. As a consequence, we might speculate that formal education enhances patients’
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